First part of information on gangs this month, plus HbA1c units compared, last bit on orthopaedic feet, a warning about phenytoin overdose and a couple of links to good relevant courses. Do leave comments below:

The value of PEWS this month, NICE on diabetes, a round up of former articles of use to the new batch of trainees and content from the paediatric orthopaedic team on funny shaped toes. Do leave comments below.

November 2015: diagnosing asthma this month, a synopsis of vitamin D deficiency as we go into the winter, a helpful cartoon around mental well-being and hypermobility demystified. All comments gratefully received!

Vitamin D deficiency in children with thanks to Dr Jini Haldar, paediatric registrar at Whipps Cross University Hospital.

Introduction

Vitamin D is an essential nutrient needed for healthy bones, and to control the amount of calcium in our blood. There is recent evidence that it may prevent many other diseases. There are many different recommendations for the prevention, detection and treatment of Vitamin D deficiency in the UK. The one outlined below is what we tend to do at Whipps Cross Hospital.

Prevention

The Department of Health and the Chief Medical Officers recommend a dose of 7-8.5 micrograms (approx. 300 units) for all children from six months to five years of age. This is the dose that the NHS ‘Healthy Start’ vitamin drops provide. The British Paediatric and Adolescent Bone Group’s recommendation is that exclusively breastfed infants receive Vitamin D supplements from soon after birth. Adverse effects of Vitamin D overdose are rare but care should be taken with multivitamin preparations as Vitamin A toxicity is a concern. Multivitamin preparations often contain a surprisingly low dose of Vitamin D.

Normal calcium (If <2.1 mmol/l in infants, refer as there is a risk of seizures)

If further assessment is required consider referral to specialist. **

Patient’s family is likely to have similar risk of Vitamin D deficiency – consider investigation ant treatment if necessary.

*Life style advice

1. Sunlight

Exposure of face, arms and legs for 5-10 mins (15-25 mins if dark pigmented skin) would provide good source of Vitamin D. In the UK April to September between 11am and 3pm will provide the best source of UVB. Application of sunscreen will reduce the Vitamin D synthesis by >95%. Advise to avoid sunscreen for the first 20-30 minutes of sunlight exposure. Persons wearing traditional black clothing can be advised to have sunlight exposure of face, arms and legs in the privacy of their garden.

2. Diet

Vitamin D can be obtained from dietary sources (salmon, mackerel, tuna, egg yolk), fortified foods (cow, soy or rice milk) and supplements. There are no plant sources that provide a significant amount of Vitamin D naturally.

As Vitamin D has a relatively long half-life levels will take approximately 6 months to reach a steady state after a loading dose or on maintenance therapy. Check serum calcium levels at 3 months and 6 months, and 25 – OHD repeat at 6 months. Review the need for maintenance treatment. NB: the Barts Health management protocol uses lower treatment doses for a minimum of 3 months and then there is no need for repeat blood tests in the majority of cases of children satisfying the criteria for management in primary care.

It is essential to check the child has a sufficient dietary calcium intake and that a maintenance vitamin D dose follows the treatment dose and is continued long term.

Follow-up:

Some recommend a clinical review a month after treatment starts, asking to see all vitamin and drug bottles. A blood test can be repeated then, if it is not clear that sufficient vitamin has been taken.

Scores of 4 or above indicate Generalised Joint Hypermobility. May be asymptomatic, or associated with joint pain (exacerbated by exercise), dislocations and fatigue. Chronic pain often leads to muscle weakness. Other associations include dizziness and syncope and gastrointestinal problems such as chronic abdominal pain and constipation.

Physiotherapy and exercises to strengthen muscles around hypermobile joints provide the mainstay of treatment. Exercises to improve balance and coordination may also be helpful as proprioception may be impaired. Occupational therapy input may be beneficial.

The Brighton Criteria (NB: Brighton, not Beighton) is used in adults to diagnose Joint Hypermobility Syndrome. To make the diagnosis you need one of: two major criteria; one major and two minor criteria; four minor criteria; two minor criteria and one affected first degree relative. The presence of an underlying syndrome excludes the diagnosis. It is not yet validated in children.

I seem to have forgotten to put a blog post up when I published April’s newsletter which contains information on: tonsillectomy for parents, erythema infectiosum (which I think my son had this week), a safety alert about bath seats, tranexamic acid in paediatric trauma and how to make a nasal douche for rhinitis sufferers.

May is now also published and features dangerous dogs, knee pain, dental caries and continuations of both the dermatology and ENT features. Do leave comments below.

Episode 4 and 5 of Jess Spedding’s minor injuries series are on the wrist.

Like in adults, the wrist is a very common location for injury. As an impulse to falling we stretch out our hands and arms to protect our head and torso, and hence the acronym FOOSH – fall on the outstretched hand, that you may come across in orthopaedic and Emergency Department documentation. The wrist is the most common upper limb fracture in adults, and is most common in children along with the supracondylar (see episode 2 of this series in December 2012 / January 2013). Whilst the supracondylar occurs in the 4-8y age group, wrist fractures which are typically distal radius fractures, can occur
at any age. Read more….

Episode 5 is on another wrist injury and one that must not be missed – scaphoid fractures. Read more….